| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
5,405 |
5,403 |
$532K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,403 |
1,319 |
$165K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,323 |
973 |
$124K |
| D1120 |
Prophylaxis - child |
1,882 |
1,880 |
$114K |
| D0330 |
Panoramic radiographic image |
2,219 |
2,219 |
$56K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
387 |
243 |
$45K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,103 |
625 |
$34K |
| D0140 |
Limited oral evaluation - problem focused |
1,951 |
1,894 |
$20K |
| D1351 |
Sealant - per tooth |
718 |
122 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
740 |
739 |
$4K |
| D0274 |
Bitewings - four radiographic images |
4,481 |
4,479 |
$2K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
16 |
14 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
4,115 |
3,970 |
$539.74 |
| D0120 |
Periodic oral evaluation - established patient |
6,098 |
6,094 |
$462.02 |
| D0272 |
Bitewings - two radiographic images |
2,085 |
2,084 |
$93.70 |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,213 |
2,473 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
6,268 |
6,265 |
$0.00 |